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Prior Authorization Form

CAREMARK FAX FORM Lidoderm

This fax machine is located in a secure location as required by HIPAA regulations. Complete information, sign and date. Fax completed forms to Caremark at 888-836-0730 Please contact Caremark @ 888-414-3125 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Lidoderm Drug Name: Patient: Patient Name: Patient ID: Patient Group Number: Patient Date Of Birth: Prescribing Physician: Physician Name: Physician Phone: Physician Fax: Physician Physician City, State, Zip:

Please circle the appropriate answer for each applicable question.

Diagnosis:

ICD 9 code:

1 Does the patient have the diagnosis of pain associated with post-herpetic neuralgia? 2 Is the skin intact (not broken, nor inflamed) where the patch is to be applied? 3 Does the patient have sensitivity to local anesthetics of the amide type (e.g., procaine, tetracaine, benzocaine)? Comments: Information given on this form is accurate as of this date.

Y Y Y

N N N

Prescriber or Authorized Signature

1

Information

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